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Health workers gearing up for more H1N1 cases in fall.

ONE SUNDAY morning in January, the Rev. Adrianne Carr stepped into her church pulpit in Burlington, Vt., to deliver her sermon.

But instead of the typical instruction on religion or morals, Carr surprised the 900 parishioners of First Congregational Church with information about preparing for pandemic influenza. Carr urged her congregants to wash their hands frequently, stockpile a three-week supply of food and, should the worst happen, stay in close touch with friends.

Carr's highly unusual sermon was tied to Vermont's "Take the Lead: Working Together to Prepare Now" campaign, part of a national effort sponsored by the U.S. Department of Health and Human Services. Burlington is one of nine U.S. communities selected by HHS in 2008 to serve as pandemic influenza preparedness "collaboratory" communities. To build the initiative, Vermont health officials enlisted local faith, business, health and civic leaders to help the community understand that the threat of pandemic flu was real, and to encourage everyone to take simple steps to prepare. As a member of the campaign's steering committee, Carr took the message straight to the pulpit and also disseminated preparedness information through the church newsletter.

"We were looking at how we could all work together to resolve the problems that would come up in the event of a pandemic influenza," Carr said. "First, we educated ourselves, and then we educated others about what it would mean."

Vermont health officials launched the Take the Lead campaign in September 2008 with a warning: It was not a matter of if a pandemic were to occur, but when a pandemic would occur. Yet no one on-hand at the initiative's launch could have predicted they were just nine months away from implementing the preparedness plans they were talking about. But the preparation paid off by bolstering the community's readiness when H1N1 influenza--also known as swine flu--first emerged, said Wendy Davis, MD, Vermont's health commissioner.

"What happened was, with all of the planning and all of the messaging we had done in the community, we were asking people very rapidly to implement those actions," Davis said. "This evolved over a matter of days and weeks, and although H1N1 cases were a little slower to come to Vermont, we started to implement our preparedness plans very quickly at the end of April. It was a very quick turnaround."


As of early July, Vermont had reported 50 confirmed cases of H1N1 influenza, with no deaths. Nineteen of the confirmed cases were in Chittenden County, home to Burlington.

With the regular flu season just around the corner, Vermont's program is but one example of how health departments and organizations across the United States are gearing up for a possible increase of H1N1 cases this fall. Like Vermont, federal, state and local health workers are incorporating lessons learned in the early months of the outbreak as they prepare for the coming flu season.

H1N1 2009, a so-called quadruple reassortant virus--containing swine, avian and human genes--was first documented in Mexico and the United States this spring. The virus causes a wide range of flu-like symptoms and is believed to spread in the same way that regular seasonal influenza viruses spread. The outbreak prompted the World Health Organization on June 11 to raise the worldwide pandemic alert level to Phase 6, indicating that a global pandemic is under way and signaling the need for response and mitigation efforts. Worldwide, more than 94,000 confirmed cases of novel H1N1 influenza had occurred as of early July, leading to 429 deaths, according to WHO. In the United States, almost 34,000 confirmed and probable cases had been reported to the U.S. Centers for Disease Control and Prevention by early July, with 170 deaths, with unofficial estimates as high as 1 million U.S. cases.

In late June, CDC officials were looking closely at H1N1 influenza activity in the world's Southern Hemisphere. As it enters into its regular influenza season, the Southern Hemisphere could provide clues about what may happen with H1N1 in the Northern Hemisphere during the fall and winter, CDC officials said. This summer, the new virus was circulating alongside the seasonal H3N2 influenza virus and other influenza viruses in the Southern Hemisphere, and hospitals in at least three countries--Argentina, Australia and Chile--were reporting difficulties coping with the numbers of people coming in for treatment. The H1N1 strain was expected to continue to spread in the Southern Hemisphere and intensify.


Among U.S. health officials' concerns is the possibility that the new strain could change and grow stronger, causing increased illness and outbreaks in the United States in the fall--just as seasonal flu makes its annual return.

"I think we are likely to see a second wave, or a wave of cases, in the fall," Stephen Redd, MD, director of the Influenza Coordination Unit at CDC, told The Nation's Health. "That's the most likely scenario; though, again, we can't predict the future."

As of late June, there had been no substantial change in the virus since the beginning of the outbreak, Redd added.

Communities look to lessons learned so far

As national health leaders monitor the situation around the country, workers at the state and local levels are addressing H1N1 in their communities. One health department that has been particularly busy is Tarrant County Public Health in Tarrant County, Texas, which had 181 confirmed cases of the virus as of early July, with no deaths.

The last weekend in April saw Tarrant County health officials working around the clock in response to the first probable case of H1N1, which occurred in a Fort Worth school.

"This was in the early stages of the national understanding of what we were dealing with," said Lou Brewer, MPH, RN, Tarrant County health director.

But health officials were ready. Within the first 24 hours, the department had crafted messages to its partners, including physicians in the community, day care centers, schools and emergency response personnel. News releases were regularly distributed, a phone bank was set up, Web site information was posted and the county's 1,500-member volunteer medical reserve corps was called in.

Brewer, who is an APHA member, said she and some of her staff worked 20-hour days during the first week of the outbreak and well into the second week.

Looking ahead to fall, multiple preparedness efforts will be implemented, Brewer said, including readying the agency's medical reserve corps and "pulling in" staff members who are not typically involved in preparedness events. Also, Brewer said she was struck by the frequency that information and guidelines were updated by CDC in the early days of the outbreak, and will factor that lesson into her fall preparedness efforts.

"In terms of doing all these things, yes, we were prepared enough, but what was different in this case was how quickly everything started happening, and how quickly the guidelines were changing," Brewer said. "The level of anxiety in the community about a novel virus really showed us that we need to be anticipating that even more over the summer."

The public's reaction in the early weeks of the outbreak shed light on the media's responsibility to provide clear, straightforward information to the public in order to allay fears and build trust, according to a report released in June by Trust for America's Health. The report, "Pandemic Flu Preparedness: Lessons From the Frontlines," noted that all the planning and preparation paid off for health officials in terms of strong coordination, communication and the ability to adapt to rapidly changing guidance from U.S. leaders.

But the report also noted that the outbreak revealed some serious gaps in the nation's preparedness for pandemic flu. Some of the gaps are directly tied to chronic underfunding and current state and local budget deficits, according to Kimberly Elliott, MA, deputy director of Trust for America's Health.

"State and local public health departments simply didn't have enough resources available," Elliott told The Nation's Health. "That was problematic, and even though this was a mild outbreak, many jurisdictions were overwhelmed."

In June, Congress and President Barack Obama passed legislation that provided emergency funding to battle pandemic flu. Health leaders hailed the supplemental funding as a much-needed measure for continuing their response to the new virus, including the development of a vaccine that might be available when seasonal flu returns in the fall. As of late June, clinical trials for a vaccine were under way, Redd said.

"One of the issues all states are concerned about is their ability to vaccinate large numbers of residents in a short time," Heather Howard, JD, commissioner of the New Jersey Department of Health and Senior Services, told The Nation's Health.

Anticipating that a safe and effective vaccine would be available by fall, CDC officials in a June 26 briefing urged state and local health departments to begin "intensifying" their planning for administering a vaccine.

For its part, the New Jersey Department of Health and Senior Services will likely be prepared, because pandemic influenza planning has long been a hallmark of the state's preparedness efforts, Howard said. The department began planning for a pandemic in 1999, she said, and New Jersey was one of the first states to create and post a pandemic influenza plan, which is part of an overarching state plan.

"It has since been revised four times and is undergoing another revision this summer based on our response to H1N1 influenza," Howard said.

The H1N1 outbreak confirmed that preparedness is key to a quick and efficient response, said Howard, whose department responded quickly by reaching out to the general public, school officials, health care providers, summer camp operators and businesses through the Web and a 24-hour hotline that received more than 3,400 calls during a 10-day period. As of early July, New Jersey had reported 833 confirmed cases of H1N1, 456 probable cases and 10 deaths.

Concerned that the virus might return at increased levels in the fall, Howard said the department is reviewing its plans to determine what has worked well and what needs to be strengthened.

Back in Burlington, Vt., Carr is familiar with a 1918 photo that depicts the First Congregational Church being used as a makeshift ward for people sickened and orphaned by the 1918-1919 flu pandemic, which caused as many as 50 million deaths worldwide. The photo confirms a sense of community in Burlington that continues today, Carr said, noting that the church stands ready to open its doors again in that capacity, should the need arise.

"My ongoing issue is basically about how we are a community to one another," Carr said.

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Publication:The Nation's Health
Date:Aug 1, 2009
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